Big love, little pay

The looming crisis in nursing homes— and what it means to you

FOR THE LOVE OF IT Lynda Villicaña chose to be a certified nursing assistant because the career allows her to work closely with the patients she cares for and comes to know well. At Twin Oaks Health and Rehabilitation Center in Chico, she assists resident Linda Holden on a walk.

FOR THE LOVE OF IT Lynda Villicaña chose to be a certified nursing assistant because the career allows her to work closely with the patients she cares for and comes to know well. At Twin Oaks Health and Rehabilitation Center in Chico, she assists resident Linda Holden on a walk.

Photo by Tom Angel

Impoverishing care: In 1996, the average nursing home cost $41,000 a year. Only one in four Americans could afford it, yet the average length of stay was 2.3 years. As a result, most families had to “spend down” until they qualified for Medicaid. Still, few people have long-term-care insurance.

Lynda Villicaña’s “childhood dream” was to become a nurse. Oddly enough, it began when she encountered an especially bad nurse.

She was 5 years old. Severely burned in an accident, she spent several months in a hospital recovering, little thanks to her primary nurse.

“She was horrible, cold and distant. She had no touch at all, even with a little girl like me,” Villicaña says. “I knew then that I wanted to become a nurse, so I could give people what I didn’t get.”

She took a job right after high school as a certified nursing assistant, or CNA, at a Chico convalescent hospital. She figured she’d gradually work her way up to licensed vocational nurse and then registered nurse.

It didn’t happen. Nurses, she discovered, do a lot of paper pushing and pill dispensing. She preferred the hands-on work of caring for patients.

“To go home at the end of the day knowing that I’ve made someone happy, that’s my reward,” she says. “To be able to hold someone’s hand at the end of life as she takes her last breath, that’s a wonderful experience.”

But she doesn’t hesitate to add, with a touch of bitterness in her voice, that she has to find her reward in the caregiving itself because financially the job is a disaster.

Although CNAs do the demanding and important work of caring for people who are sick and often old and dying, the starting wage is around $8 per hour, little more than most—and less than some—fast-food workers and retail clerks make. And caregivers work in a 24/7 environment, which means weekend and night shifts for many.

As a result, it’s become increasingly difficult to keep nursing homes fully staffed. As Villicaña puts it, “If people can work at Burger King for almost the same pay, why would they want to come here and wipe somebody’s butt?”

Today, California’s skilled-nursing facilities—which are sometimes called convalescent hospitals or nursing homes—are collectively understaffed by 30,000 employees, especially CNAs but also licensed vocational nurses, registered nurses, dieticians, physical therapists and housekeepers—just about everybody, in short.

In June 2001, the state Department of Health Services reported that fully one-third of California’s nursing homes failed to meet minimum staffing requirements.

The shortage of registered nurses is especially acute, as they can make considerably more money working for hospitals, especially now that so many hospitals are unionized and also facing serious staffing shortages of their own.

To make matters worse, the number of Californians over the age of 65 is expected to double by 2020, as the baby boomers become elderly, and fully 40 percent of them will need nursing home care at some time. The way things are going, it’s won’t be there for many of them, and those who do find an opening will be more likely to suffer from worsened quality of care.

As it is, horrifying instances of neglect seem almost commonplace in the industry: oldsters with bedsores left to fester for days or with untreated broken bones from falls; people not getting enough liquids and, as in at least in one recent, notorious case, dying from heat and thirst.

Such incidents are dramatic and hit the news, but they don’t happen every day, obviously. Still, the industry is under stress, and even in Chico there have been problems. In 2001, an 80-year-old died at Enloe Medical Center from respiratory arrest due to urinary tract infection (he was on a catheter) after his nursing home failed to assess his “very low food and liquid intake” as recorded on his chart. It was fined $80,000.

Bad things happen, even in the best nursing homes, more often in the bad ones. They all suffer from staffing pressures, including high turnover (as much as 100 percent annually), and all face periods when their staffs are shorthanded.

Anne Burns Johnson is president and CEO of the California Association of Homes and Services for the Aging, a Sacramento-based group that represents nonprofits that provide affordable housing and continuum-of-care services for the elderly, including nursing homes. Of the state’s 1,600 nursing homes, about 200 are nonprofit.

There are many reasons why nursing homes are facing a severe staffing shortage, she explains, but underlying them all is the fact that our society simply doesn’t place much value on personal-care services. “We don’t value child care, and we don’t value custodial or long-term care of the elderly,” she says.

Being a childcare worker or a CNA doesn’t require extensive education, she explains, so the jobs don’t command high wages and turnover is high. And yet both involve caring for vulnerable loved ones. And, in the case of nursing home residents, the people being cared for are old, sick and extremely frail. “It’s very easy for things to go wrong very fast,” Johnson says, a situation that is exacerbated by staffing problems.

“Sometimes we can’t find anybody to fill [vacancies], no matter what,” says Maura Miller, director of nursing at Villicaña’s facility, Twin Oaks Health and Rehabilitation Center, in east Chico. Recruiting new employees is a constant task involving advertising and attending job fairs and college career days and hoping word of mouth helps, she says.

Twin Oaks is caught between its owner’s need, and right, to make a profit and strictly set reimbursement levels—the proverbial rock and hard place. Most of its income, 70-80 percent, comes from Medi-Cal and Medicare. And state legislators have mandated that residents receive at least 3.2 hours of direct care each day, on average.

Medi-Cal now pays an average of $115 per patient per day. That may seem like a substantial amount, but it must include food, therapy and recreational services and 24-hour personal care as well as lodging. It’s hard to find a decent big-city hotel room for $115.

The nonprofits are able to pay slightly higher salaries, Johnson notes, because they don’t have to make a profit and pay taxes. And, generally, their primary motivation is to provide a service, whereas some for-profit companies—though not all—are in it just for the money.

Changes are on the way, but the state’s current budget crunch may make them moot.

A bill passed and signed last year, AB 1075, authored by Assemblyman Kevin Shelley, D-San Francisco, requires that staffing mandates be reassessed by 2003 and Medi-Cal reimbursement rates be adjusted to reflect acuity levels.

Shelley’s purpose is to make staffing and reimbursement more accurately reflect the variety of patients and levels of care they need. Task forces are working on both fronts. But, as Johnson points out, if they accurately assess the need, they will have no choice but to ask for more money, particularly for staffing. And, at a time when the state faces a massive shortfall—$24 billion this year alone—such increases are unlikely.

In the meantime, federal Medicare reimbursement rates are set to go down, not up. Effective Oct. 1, they will drop by 17 percent, an estimated decrease of $240.5 million in California alone. Currently, Medicare pays significantly more than Medi-Cal, and facilities compete for Medicare patients. But Medicare covers only limited stays for specific treatment after hospital stays, not long-term care.

In the meantime, most facilities are getting old. Few new ones are being built, Johnson reports, especially on the for-profit side, which has seen numerous bankruptcies in recent years. There’s simply little capital available for construction, she says.

All of this adds up to a disaster in the making: A flood of oldsters needing nursing care, few of them with private insurance, trying to find openings in too-few facilities, of which many if not most are seriously understaffed.

Meanwhile, dedicated CNAs like Villicaña wait and hope. She has watched many of her colleagues move on, mostly for money. She’s fortunate that her husband has a good job, at the Manville plant in Willows. But she has three kids, and she wants them to do things like play sports in school, which costs money. “Where’s it gonna come from?” she wonders.

Being a CNA is “mentally demanding, it’s physically demanding—very exhausting,” she says. But, all complaints aside, she loves working at Twin Oaks.

“If you have a big heart, an open heart, it’s an extremely rewarding place to work," she says. "If you have a lot of love to give, there are a lot of residents here who would love to share it with you."